Covered with criteria (selected rows in this file segment). Services listed below are covered as preventive care when the specified age limits, diagnosis code requirements, frequency limits, and other listed conditions are met. Codes noted as not having diagnosis requirements may still be subject to other policy rules (site of service reviews, prior authorization, plan exclusions).
ALL of the following
ALL of the following
Patient age 45-75 years (ends on 76th birthday)
When using preventive colonoscopy procedure codes G0105 or G0121 no diagnosis code is required; other colonoscopy codes marked with * are preventive only when billed with one of the listed screening diagnosis codes or billed in addition to specified screening codes (see coding guidance)
Fecal occult blood test (FOBT)/FIT and fecal DNA screening: age 45-75; fecal DNA limited to once every 3 years
Refer to Screening Colonoscopy Procedures - Site of Service and Outpatient Surgical Procedures - Site of Service for possible site-of-service review
type":"criteria_group"},{"citations":["chunk 22","chunk 26"],"intro":"Abdominal Aortic Aneurysm (AAA) Screening — covered when ALL of the following are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"USPSTF recommendation: 1-time screening with abdominal ultrasound for men aged 65-75 years who have ever smoked\"},{\"text\":\"Age 65 through 75 (ends on 76th birthday)\"},{\"text\":\"Requires at least one of the listed diagnosis codes (e.g., history of tobacco use codes) when billing the screening ultrasound procedure code 76706\"}]}"],"title":"Abdominal Aortic Aneurysm Screening","type":"criteria_group"},{"citations":["chunk 23","chunk 31"],"intro":"Chlamydia and Gonorrhea Screening — covered when ALL of the following apply:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Screening applies to asymptomatic, sexually active women (per USPSTF) and pregnant persons as specified\"},{\"text\":\"Chlamydia and gonorrhea lab procedure codes require a pregnancy diagnosis code for pregnant persons or one of the listed screening diagnosis codes for preventive benefit to apply\"},{\"text\":\"When blood draw codes (36415/36416) are used they must be billed with the appropriate lab code (e.g., 86631/86632) and an allowed screening diagnosis code or pregnancy diagnosis code\"}]}"],"title":"Chlamydia and Gonorrhea Screening","type":"criteria_group"},{"citations":["chunk 26","chunk 28"],"intro":"Hepatitis B and C Screening — covered when the following are met:","nodes":["{\"operator\":\"any\",\"children\":[{\"text\":\"Hepatitis C: USPSTF recommends screening for adults age 18-79; no diagnosis code required for preventive benefit to apply when using listed procedure codes (86803, 86804, G0472)\"},{\"text\":\"Hepatitis B: screening recommendations apply for pregnant persons and at-risk populations; when billed for pregnancy screening a pregnancy diagnosis code is required or one of the screening diagnosis codes listed in the row\"}]}"],"title":"Hepatitis B and C Screening","type":"criteria_group"},{"citations":["chunk 28","chunk 121"],"intro":"HIV Screening — covered when the following criteria are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"USPSTF: screen adolescents and adults aged 15-65 and all pregnant persons; no age limit for preventive benefit where codes and diagnosis requirements are met\"},{\"text\":\"HIV screening procedure codes must be billed with either a pregnancy diagnosis code for pregnant persons or one of the listed screening diagnosis codes to qualify as preventive\"},{\"text\":\"Blood draw codes must be billed with the HIV screening lab code and appropriate screening diagnosis code\"}]}"],"title":"HIV Screening","type":"criteria_group"},{"citations":["chunk 31","chunk 32"],"intro":"Genetic Counseling and BRCA Lab Screening — covered when ALL of the following are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Use a validated familial risk assessment tool to identify women with personal or family history suggestive of BRCA1/2 mutations\"},{\"text\":\"Women with a positive brief risk assessment should receive genetic counseling (procedure codes 96041, S0265 or allowed E/M codes)\"},{\"text\":\"BRCA laboratory testing (listed CPT codes 81162–81167, 81212, 81215–81217) is covered only if indicated after genetic counseling and when required diagnostic counseling codes/diagnosis codes are present in the primary position\"},{\"text\":\"Prior authorization requirements apply to BRCA lab screening per plan rules\"}]}"],"title":"Genetic Counseling and BRCA Lab Screening","type":"criteria_group"},{"citations":["chunk 34","chunk 35","chunk 37"],"intro":"Diabetes and Prediabetes Screening and Preventive Interventions — covered when ALL of the following are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Diabetes screening (ADA/USPSTF aligned): adults age 35-70 with overweight or obesity for the preventive benefit for prediabetes/type 2 diabetes (ends on 71st birthday)\"},{\"text\":\"Diabetes screening procedure codes require one of the Required Screening diagnosis codes (Z00.00, Z00.01, Z13.1) AND one of the Additional Diagnosis codes (e.g., overweight/obesity codes) for the preventive benefit to apply\"},{\"text\":\"If any diabetes diagnosis code is present in any position the preventive benefit does not apply\"},{\"text\":\"Preventive interventions (medical nutrition therapy, counseling, behavioral counseling codes) are limited to the specified age range and diagnosis requirements when noted; counseling codes may have frequency limits per code guidance\"}]}"],"title":"Diabetes and Gestational Diabetes Screening","type":"criteria_group"},{"citations":["chunk 37","chunk 39","chunk 180","chunk 179"],"intro":"Screening Mammography and Breast Imaging to Complete Screening — covered when the following criteria are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Screening mammography (77063, 77067) is a preventive benefit with no age limit per codes listed; follow USPSTF and HRSA guidance for initiation and frequency (HRSA: initiate between age 40–50 and at least biennially)\"},{\"text\":\"Additional imaging (diagnostic mammography codes, breast ultrasound, breast MRI, contrast materials) to complete the screening process is covered when required to complete screening or address findings; diagnostic imaging may require an average-risk diagnosis code when specified\"},{\"text\":\"Revenue code 0403 (screening mammography) and related codes may apply; check coding guidance for average-risk diagnosis lists and plan-specific rules\"}]}"],"title":"Screening Mammography","type":"criteria_group"},{
citations":["chunk 43","chunk 41","chunk 62","chunk 105","chunk 111"],"intro":"Cholesterol / ASCVD Risk Screening and Behavioral Counseling for Cardiovascular Risk — covered when the following apply:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Cholesterol screening procedure codes (80061, 82465, 83718–83722, 84478) apply for ages 40-75 (ends on 76th birthday) and require one of the listed diagnosis codes for the preventive benefit to apply\"},{\"text\":\"ASCVD risk assessment and counseling codes (G0537, G0538) are available for ages 40-75; diagnosis codes listed are not required for G0537/G0538\"},{\"text\":\"Behavioral counseling interventions for diet/physical activity and for high BMI are covered when billed with the listed procedure codes and when diagnosis code requirements are met; some codes (e.g., G0446) have frequency limits (once per year)\"}]}"],"title":"Cholesterol / ASCVD Risk Screening","type":"criteria_group"},{
citations":["chunk 48","chunk 49","chunk 50"],"intro":"Colorectal Cancer Screening (Preventive) — grouped preventive colorectal screening conditions and instructions:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"USPSTF recommends screening adults age 45-75 (ends on 76th birthday) using one of the recommended modalities (screening colonoscopy, sigmoidoscopy, FOBT/FIT, fecal DNA, CT colonography)\"},{\"text\":\"Codes G0105 and G0121 do not have diagnosis code requirements for the preventive benefit; other procedural codes marked with * are preventive only when billed with specified screening diagnosis codes or in conjunction with G0104/G0105/G0121/G0328/S0285 as noted\"},{\"text\":\"Pre-op consultation S0285 is preventive when billed with one of the listed office visit codes and the listed screening diagnosis codes\"}]}"],"title":"Colorectal Cancer Screening (Preventive)","type":"criteria_group"},{
citations":["chunk 53","chunk 54","chunk 56","chunk 57"],"intro":"Wellness and Newborn Screening — covered when the following apply:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Wellness examination codes (preventive E/M, counseling, newborn evaluation) do not have diagnosis code requirements for the preventive benefit to apply for general wellness codes; HRSA requirements for well-woman visits are included where applicable\"},{\"text\":\"Newborn screenings (hypothyroidism, phenylketonuria, metabolic panels) apply to all newborns age 0-90 days and do not have diagnosis code requirements for the preventive benefit; blood draw codes require age-based applicability\"},{\"text\":\"Application of topical fluoride (99188) is preventive for age 0-5 years (ends on 6th birthday) with no diagnosis code requirement\"}]}"],"title":"Wellness and Newborn Screening","type":"criteria_group"},{
citations":["chunk 60","chunk 62","chunk 84","chunk 85","chunk 103","chunk 104","chunk 105","chunk 110","chunk 111","chunk 112","chunk 114"],"intro":"Behavioral and Mental Health Screenings, Prevention, and Counseling — covered when criteria are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Depression screening in adults (96127, 96161, G0136, G0444) per USPSTF is covered; some codes require a screening diagnosis code for 96127 while others do not\"},{\"text\":\"Anxiety screening (96127) is covered per USPSTF; requires diagnosis code Z13.39 when indicated\"},{\"text\":\"Behavioral counseling to reduce unhealthy alcohol use, to prevent STIs, and to address obesity/weight loss are covered using listed counseling codes when diagnosis code requirements (if any) are met and frequency/age limits are observed\"}]}"],"title":"Behavioral and Mental Health Screenings","type":"criteria_group"},{
citations":["chunk 120","chunk 121","chunk 124","chunk 127"],"intro":"Lung Cancer Screening (LDCT) and PrEP (HIV Prevention) — covered with criteria:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Lung cancer screening with LDCT (CPT 71271) is covered when ALL of the following are met: age 50-80 years (ends on 81st birthday); ≥20 pack-year smoking history; current smoker or quit within past 15 years; limited to one per year; requires one of the listed tobacco-related diagnosis codes\"},{\"text\":\"Preexposure prophylaxis for HIV (PrEP) is covered when billed with required primary diagnosis codes (e.g., Z11.3, Z11.4, Z20.2, Z20.6, Z29.81, Z72.51–Z72.53) in the primary position; ongoing monitoring codes (kidney function testing, pregnancy testing, and periodic office visits) are required per USPSTF guidance; prior authorization may apply depending on plan and pharmacy benefit administrator\"}]}"],"title":"Lung Cancer Screening and PrEP","type":"criteria_group"},{
citations":["chunk 129","chunk 130","chunk 139","chunk 141"],"intro":"Pediatrics and Preventive Developmental/Screening Services — covered when criteria are met:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Bright Futures–recommended services (hearing tests, vision screening, formal developmental/autism screening, anemia screening, ECG risk assessment when indicated) are covered per the age ranges and diagnosis code guidance in the applicable rows\"},{\"text\":\"Hearing tests: procedure codes listed; ages 0-90 days do not require a diagnosis code; ages 91 days–21 years require an appropriate diagnosis code and are limited to once per year\"},{\"text\":\"Formal developmental/autism screening (96110) applies prenatal to age 2 (ends on 3rd birthday) and requires one of the listed diagnosis codes; no frequency limit specified unless otherwise noted\"}]}"],"title":"Pediatrics and Developmental Screening","type":"criteria_group"},{
citations":["chunk 144","chunk 149","chunk 150","chunk 151","chunk 157","chunk 165","chunk 166","chunk 169","chunk 170","chunk 173"],"intro":"Expanded Women's Preventive Health — covered with criteria (HRSA/WPSI-aligned services):",
nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Well-woman preventive visits and related services (preventive E/M, pelvic examination add-on 99459 when applicable) are covered to support delivery of recommended preventive services for women age 15 and older per HRSA/WPSI requirements\"},{\"text\":\"Contraceptive services, counseling, provision, and follow-up (codes listed across code groups) are covered when diagnosis and code-group specific requirements are met; some services require specific diagnosis codes to qualify as preventive\"},{\"text\":\"Postpartum visits (59430) and screening for gestational diabetes and diabetes after pregnancy follow HRSA guidance; diabetes screening in pregnancy requires a pregnancy diagnosis code and will not be applied if a diabetes diagnosis code is present in any position\"},{\"text\":\"Breast cancer screening for women at average risk (mammography codes 77063, 77067) is covered with no diagnosis code requirement; additional imaging to complete screening requires appropriate average-risk diagnosis codes when specified\"}]}"],"title":"Expanded Women's Preventive Services","type":"criteria_group"},{
citations":["chunk 179","chunk 180","chunk 181","chunk 182","chunk 183","chunk 184","chunk 185","chunk 186","chunk 187"],"intro":"Additional operational notes and payability caveats — consolidate important billing rules and exceptions:","nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Certain codes may not be payable in all circumstances due to other policies or guidelines (e.g., site-of-service reviews, medical necessity, existing diagnosis codes, or separate medical policies). Refer to Coverage Rationale and related Medical Policies for details\"},{\"text\":\"Preventive care medications are administered through the pharmacy benefit; refer to the member's pharmacy plan administrator for coverage and reimbursement details\"},{\"text\":\"Services required solely for employment, school, travel (including travel vaccines), licensing, insurance, judicial/administrative orders, or research are excluded from the preventive benefit\"},{\"text\":\"Employer-level religious exemptions may apply for contraceptive coverage; member-specific benefit governs coverage. Prior authorization may apply for select laboratory tests (e.g., BRCA) and imaging or for long-acting injectable agents per the applicable drug policies\"}]}"],"title":"Operational Notes and Exclusions","type":"criteria_group"}],
id":"coverage-criteria","label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"} PMID: N/A
id":"coverage-criteria","label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
title":"Coverage Criteria for Preventive Services"}]},
id":"coverage-criteria","label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
id":"coverage-criteria","label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
title":"Coverage Criteria for Preventive Services"}]}
id":"coverage-criteria","label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
id":"coverage-criteria","label":"COVERAGE CRITERIA","title":"Coverage Criteria for Preventive Services"}
title":"Coverage Criteria for Preventive Services"}